Predictors of adherence and outcome in schizophrenia
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Transcript of Predictors of adherence and outcome in schizophrenia
Predictors of adherence and outcome in schizophrenia
Richard Drake,Senior Lecturer in Adult Psychiatry,
University of Manchester
What I’m Going to Tell You• Non-adherence predicts poor outcome• Determinants of adherence and
concordance – Insight relates to degree of concordance
• Poor insight predicts poor outcomes– it may predict poor outcome better than
adherence• Insight and adherence can be changed
Predictors of Outcome in Schizophrenia
• Demographic– Sex, age
• Historical– Premorbid adjustment– DUP, Course of illness– Symptoms
• Behavioural– EE, Substance Misuse – Adherence, Engagement
Predictors of Outcome in Schizophrenia
• Demographic– Sex, age
• Historical– Premorbid adjustment– DUP, Course of illness– Symptoms
• Behavioural– EE, Substance Misuse – Adherence, Engagement
Davis & Andrukaitis 1986 J Clin Psychopharmacol
16.2% 57.6%
Drug Placebo
Davis & Andrukaitis 1986 J Clin Psychopharmacol
Adherence and Chronic Illness
• Stopping APS suddenly: 46% relapse in 6/12 if stable56% in two years
• Stopping gradually: 50% over 2 years
Viguera et al 1997
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Survival (%)
Robinson D et al, Arch Gen Psych, 1999
Gaebel W et al 2002 Sz Res
Gaebel W et al 2002 Sz Res
Wunderink L et al 2005, 2007
MESIFOS STUDY
Determinants of Poor Adherence
• Maybe – isolation, youth and being male– substance abuse – more side effects or their subjective
experience – more frequent doses– Better or worse cognitive function
• Or not, for most of the above
More recent studies• Internal rather than external locus of
control• High EE family• Poor therapeutic alliance• Negative attitudes • Poor insight
Influence of Others
Belief in Prevention
Medication Affinity
Vauth R et al, 2004 Psychiatry Res
Influence of Others
Belief in Prevention
Medication Affinity
Meaningful Work
Neuro-cognition
Length of Illness
No symptoms
Age
Vauth R et al, 2004 Psychiatry Res
Insight and medication attitudes
Day, J., et al. 2005 Arch Gen Psych 62 717-24
Insight and medication attitudes
Day, J., et al. 2005 Arch Gen Psych 62 717-24
The Construct of Insight• Insight said to have different
dimensions– E.g. recognising sx, illness, its social
consequences, & need for Rx; attributing sx to illness; “hypothetical contradiction”
• Insight appears to have cultural, symptomatic and neuropsychological determinants
Insight and Outcome• In chronic samples predicts relapse,
readmission, symptoms, objective QoL, adherence, other outcomes– perhaps including violence (esp. in short
term or in forensic populations).– Perhaps not including engagement?
• Insight during the process of relapse predicts readmission.
• However, these samples select for poor IS
Why does RLS predict relapse?
• Re-Labelling Symptoms predicts relapse– Unlike accepting NFT, awareness of
illness• Chance finding?• Related to identifying relapse?• Related to substance misuse, EE?• Related to adherence?
Recent FE naturalistic studies
• Poor adherence in FE– definitions vary but most involve
stopping >7/7 as a minimum– Many of these will stop altogether for
some time– 33% over any 6 months– 42-59% at some point over 1-5years
• All multivariate analyses of predictors of adherence have global insight as significant– Except Coldham et al, 2002
• IS predicts irregular or non-adherence• Disappears when adjust for PM function,
age, cannabis at 1y, family support
Recent FE naturalistic studies
HBM and Adherence in a Trial
• Perkins et al. 2006: FE trial of APS in 254• Small effect of objective SE predicted
non-adherence• Lack of benefit too• Negative attitudes to medication did not• Awareness of benefits of medication in
reducing sx. & NFT both predicted good adherence
IS and Adherence in a Trial• McEvoy et al. 2006: FE trial of 251
OLZ v HPL• ITAQ scale predicted time to non-
adherence• Type of medication did not
FE cohorts and trials• Global IS predicts adherence even after
attitudes to medication• In detail, awareness of past and future
symptom reduction predicts continued adherence
• Negativity about medication or perceived SE not predictive; possibly objective SE
• Other aspects of insight inconsistent
Insight may be improved• Specific IS-focussed CBT may
improve it (Turkington et al, 2002, 2006; Rathod et al 2005)– This form of CBT protected against
depression• Focussed CBT may alter attitudes to
illness and self (Gumley et al, 2005)• General CBT for psychosis may not
improve IS or suicidality (Tarrier et al, 2006)
Adherence may be improved
• Psychoeducation about medication almost never effective
• Multi-modal interventions appear more likely to be effective – certainly more fashionable
Insight and medication attitudes
Day, J., et al. 2005 Arch Gen Psych 62 717-24
Adherence may be improved
• Combine education about meds & disorder with:– Behavioural approaches (techniques and
skills, reminders, reinforcement)– Work on therapeutic relationship– Use other interpersonal relationships,
feelings of loyalty etc. (“affective approaches”)
• May be effective individually, in groups or via services (e.g. supported housing)
Summary• Certain attitudes may be more
predictive of future adherence and relapse than current behaviour– There maybe a very disadvantaged
subgroup– Sealing over may predict
disengagement
Summary• Insight is associated with suicidality
– If you then become depressed and hopeless because you’re ashamed and overwhelmed
– It doesn’t help if you abuse substances• Insight leads to adherence and
improvement, which prevents the above• Specific CBT might improve IS without
depression• Multimodal interventions improve
adherence
P D
SE
NFM
+ve correlation -ve correlation
Well
AIS
DSH
Hosp